By Accident or design?

29/05/2013 - 10.28

There has been much press coverage recently concerning the apparent crisis in emergency services, and in particular the provision of care within hospital emergency departments.

In remaining clinically active I am able to appreciate first hand some of the problems associated with continuing to provide high quality and effective emergency care which has been the hallmark of UK systems. Many other countries envy the way in which, since mandated by the Government in 2001, we have managed to see, treat, discharge or admit 98% of patients in the emergency department (ED). Many envy the way in which this service driven target has empowered and enabled nurses and other non-medical staff to take on a more independent role in providing care; in the department where I am employed I work alongside paramedics, physiotherapists and physician assistants in providing care to patients without the requirement for them to wait and be seen by medical staff.

Disadvantages of this target driven culture were amply highlighted in the Francis Report into the crisis at Mid-Staffordshire hospital; the consequences of failure were seen as so great that any means were employed to achieve them. The pressure to ‘process’ patients to discharge or admission is great and I have had to move some patients that I have seen simply to meet the 4 hour standard – whether this was in the patients best interests or not. The problem as I see it is two-fold.

Firstly, the 4 hour standard has always been seen as an emergency care target rather than a target for the whole health set up – thus many patients may be moved inappropriately to meet the standard simply because bed occupancy in hospitals is so high – the Department of Health recommends occupancy levels of around 85%, whereas many are at least 10% higher than this. One of the principle underlying reasons for this is a continued lack of seven day working in the NHS – problems are invariably more acute at the beginning of the week when patients who could have been discharged over the weekend have to wait until Monday or Tuesday for someone in a senior enough position to make this decision.

Secondly, GP and primary care services are limited and patients have a very poor perception of them; since 2004 GPs have been able to opt out of the provision of ‘out of hours’ care and many indeed have. Private providers have taken their place and this has often been to the detriment of patient trust and even patient welfare, such as in the well publicised case of the German locum GP flown in for a weekend’s work who overdosed a patient with morphine - the patient subsequently died. The public appear to have little faith in primary care services – I will often hear people say things like ‘they would have sent me here anyway’, ‘I couldn’t get an appointment for 10 days’ when attending the ED. The new 111 telephone system appears to have exacerbated this, with some reporting a 25% increase in workload.

In short, hospital emergency departments are struggling because they are not supported by other areas within the hospital, or by services provided to patients in the community.